NVAC Influenza Vaccine Recommendations and Strategies Subgroup Members: Jerome Klein (Chair), Jeff Davis, Jon Abramson, Carolyn Bridges, Nancy Cox, Ben Schwartz, Jane Seward, David Shay, Lone Simonsen,

Subgroup Objectives Examine data on influenza disease burden and vaccination program impacts Determine whether current surveillance provides adequate data to monitor burden & impact Suggest strategies to improve surveillance Consider potential alternate influenza vaccination strategies and identify critical issues that NVAC can address as they are being evaluated

Estimating Influenza Disease Burden Challenges Annual variation in disease No pathognomonic syndrome and infrequent etiological diagnosis May present without respiratory symptoms and may contribute to exacerbations of non-respiratory illnesses (e.g., CHF) Modeled disease burden estimates ~36,000 respiratory and circulatory deaths per year

% vaccine coverage Excess P&I Mortality per 100,000 pop Influenza season during , US Trends in Pneumonia & Influenza (P&I) Mortality and Influenza Vaccine Coverage Simonsen, unpublished data Unadjusted data, age 65+

Excess All-Cause Mortality, , “Young Elderly”

Excess P&I and All-Cause Mortality, , “Older Elderly”

Caveats and Conclusions Caveats Ecological data are inconsistent with case-control and cohort studies showing significant impacts of influenza vaccine on hospitalization and death Conclusions A substantial number of influenza associated deaths occur despite the vaccination program Influenza vaccine effectiveness is lower in the elderly compared with younger persons Vaccination coverage in the elderly has not increased in recent years

U.S. Influenza Surveillance: Objectives and Systems ObjectiveSystem Identify strains causing illness Public health and hospital lab networks test clinical specimens Monitor morbidity nationally and by state Sentinel provider network – rates of influenza-like illness State/territorial epidemiologist reports Monitor national P&I mortality 122 city death certificate review for P&I as cause of death Identify cases/outbreaks for investigation Reports to CDC from health departments and hospitals

U.S. Influenza Surveillance: Gaps No data on rates of influenza disease or death No routine monitoring of vaccine effectiveness

Recent and Proposed Enhancements to Influenza Surveillance New Vaccine Surveillance Network Population-based surveillance for influenza hospitalization in children <5 y.o. in 3 metro areas Prospective, sensitive diagnostic testing on all children admitted with febrile or respiratory illness Emerging Infection Program Sites Identify positive influenza diagnostic tests in children from 10-population based surveillance sites National reporting for influenza deaths in children (proposed to CSTE) CDC RFA for annual influenza VE studies

Subgroup Recommendations: Disease Burden, Program Monitoring & Impact Expand active, prospective surveillance with etiological diagnosis in sentinel populations of children and adults Collaborate with health care organizations to obtain rapid turn-around data on ILI and documented influenza for VE studies Meet to evaluate different methods of estimating program impacts; propose studies, as needed, to resolve differences Provide support for expanded surveillance activities

New Influenza Vaccination Strategies Subgroup supports ACIP evaluation of expanded (universal?) influenza vaccination Potential NVAC roles Assessment of vaccine supply issues Assessment of vaccine delivery strategies (e.g., in schools) and delivery technologies (e.g., intranasal, patch) Assessment of vaccine financing options Assessment of universal vaccination programs in other areas (e.g., Ontario, Canada)